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SHOULDER PAIN – The Big Three

“My shoulder hurts, Doc”.  This is a common complaint heard by the orthopedist. The history is remarkably consistent:  gradual onset of increasing shoulder and upper arm pain, with or without a preceding, usually minor, injury.

The diagnosis is most often one of three conditions we`ll call “the Big Three”:  Rotator Cuff Tedinopathy, Adhesive Capsulitis, and Osteoarthritis of the Shoulder. Though similar in presentation, these conditions differ markedly in pathology (what is wrong anatomically and microscopically) and etiology or cause.

• Rotator cuff tendinopathy is a common problem in which shoulder motion, though full, is painful. This pain is worsened when the arm is used away from the body, as in throwing a ball.  The underlying cause of this condition is degenerative: fraying of the cuff’s attachment to bone. This wear and tear phenomenon is not surprising given the stress these short muscle undergo counterbalancing their long lever, the arm.
• Adhesive capsulitis or “frozen shoulder” is characterized by stiffness with marked pain at the extremes of motion. These people cannot reach around to scratch their backs, and throwing off the bed covers in the morning causes severe pain.  The pathology in this entity consists of an inflamed capsule that thickens and undergoes contracture, all of which lead to pain and loss of motion.  The etiology is unknown, but autoimmunity is believed to play a role.
• Osteoarthritis of the shoulder joint is characterized by gradual onset of pain and stiffness with the pain being less intense than the previous two conditions.  Here, the joint surface becomes rough and worn, reducing motion and inducing a dull low grade pain. The origin of osteoarthritis is multifactorial and may include prior trauma or a genetic propensity.

Initial treatment for each of the Big Three is conservative, consisting of physical therapy (stretching, strengthening, education on care of the shoulder for the particular diagnosis), a steroid injection and a measure of time, the latter based on knowledge of the natural history of the particular condition.  In rotator cuff tendinopathy, surgery is considered if conservative therapy fails to bring relief after a few months or initially if there is suspicion that the cuff had been torn by a precipitating injury.  An MRI is almost always used in the surgical decision making.  Frozen shoulder is a self limiting disease, though its protracted course of 6-18 months can try the patience of both doctor and patient.   Steroids injected into the shoulder joint within the first few months of onset can sometimes dramatically reduce pain and shorten the natural course. The shoulder joint afflicted with osteoarthritis often tolerates its burden surprisingly well. A regular program of stretching and strengthening is often all that is needed to maintain reasonable function and a pain level that is tolerable.  For those patients with recalcitrant pain and stiffness, shoulder replacement offers an excellent alternative.

With the possible exception of low back pain, shoulder pain is the most common complaint heard in a general orthopedic practice. Although there are many causes, the vast majority are one of the Big Three, with rotator cuff dysfunction being by far the most common.  Fortunately, in most cases, proper education and rehabilitation can return this complex but fascinating structure we call the shoulder to a high level of function.

This is an update on Osteoporosis (OP) and Fragility Fractures (FFs), conditions initially introduced in our October and December 2010 columns.  I recommend a review of those earlier columns. A brief summary is as follows:     

• OP is defined as “thin bones “and is due to inadequate calcification of the skeleton
• FFs are fractures through these weakened bones and occur following minor trauma
• Bisphosphonates (BPs) are a class of drugs proven to reduce the risk of FFs and improve skeletal calcification
• Post menopausal women are at high risk for developing OP

 OP and its sequelae, FFs, are increasing at an alarming rate in the United States. There are more FFs each year than heart attacks, strokes and new cases of breast cancer combined.

A program of exercise, adequate calcium/Vitamin D intake (especially during the prime growth years of 8-18) and, when indicated, BPs, has been proven to reduce significantly the risk of OP and its complications. Despite this evidence, misconceptions and distrust abound, keeping compliance and participation low.

Let us review some fears, facts, and current thinking on OP.

         Fear: “Bisphosphonates cause femur (thigh bone) fractures rather than prevent them.”

Fact:  BPs can cause femur fractures, but it’s rare. Actually, BPs prevent as many as 100 femur fractures to every one they may cause.  This rare event, moreover, seems to occur in persons taking BPs for longer than 5 years, the point at which many patients can safely stop the drug as their bone mass may well have stabilized.

         Fear:  “Calcium supplements can cause heart attacks”

Fact:  This causal relationship, though implied in recent studies, has not been proven.  Because of this possible connection, however, the recommendation is to obtain most of one’s daily calcium requirement through dietary means.  Dietary calcium has not been linked to heart attacks.

         Fear:  “OP is the accepted cost of aging and FFs are relatively uncommon, especially if one is careful”

Fact:  Fifty per cent of women over age 50 will have a FF in their lifetime. This serious complication of OP is largely a preventable condition if prophylactic recommendations are followed.  Being careful is not enough.

Here are the current OP recommendations for all adults over 40:

1. All post-menopausal women need to be screened for OP
2. Everyone with a FF, regardless of age or sex, needs to be evaluated and treated for OP; without treatment, the chance of a second FF is very high
3.  Take 1000-1200mg of Calcium (dietary preferred) and 400-800 IU of Vitamin D supplements each day
4. Engage in daily weight bearing exercises using the upper extremities as well as the lowers
5. Do not smoke
6. Limit alcohol to no more than two drinks a day
7. Take BPs if prescribed; while taking BPs, be cognizant of any persistent thigh pain and report it to your doctor. After 5 years of continuous use of BPs, discuss possible cessation with your doctor; do not stop them on your own

 OP, like Hypertension, is a silent disease, slowly progressing without causing symptoms.  In both conditions proactive treatment will avert serious complications.

NHOC will be open during regular business hours on Monday 12/24, and also regular business hours on Monday 12/31. We will be closed on Tuesday 12/25, but a physician will be on-call for emergencies as always.

We all know that to be successful in a sport we must get in shape. Did you know the same principle applies to surgery? Just as running a marathon takes its toll on the body, so does surgery. Recovering optimally from both requires planning and preparation.

Stop Smoking

Even a few weeks of not smoking prior to surgery reduces the risk of post op breathing complications. This has particular importance to the orthopedic surgeon since smoking impairs bone healing.

Stop Excess Alcohol Intake

What constitutes “heavy drinking” is somewhat controversial, and its effect on liver function varies from person to person. If you have more than 2 to 3 drinks a day, however, consider stopping or at least reducing your intake well before your surgery date. The liver breaks down many of the medications used during your hospitalization. You want it at its best.

Exercise

Continue to exercise, even if it causes some discomfort. There are very few medical conditions that are not helped by exercise. Athletes, regardless of age, tend to be “quick healers” . This is in large part due to their commitment to exercise. By staying active right up until surgery, you too can be “athletic” and improve your chances for a rapid recovery.

Eat Healthfully

Poor nutrition can impair wound healing. If your diet is not balanced, and you think you might be malnourished, talk to your primary physician. A dietary consultation and/or blood tests can determine if you would benefit from nutritional supplements prior to and after surgery. Remember, overweight people can be just as malnourished as thin people.

Address Emotional Issues

Anxiety and depression can have a detrimental effect on your post op functional recovery. Make sure you understand the reasons for surgery and the rehabilitation goals expected of you after surgery. If you feel you need emotional support, talk to your surgeon or primary physician. He or she will refer you to the appropriate professional.

Unlike emergencies, elective surgery gives us a chance to plan ahead. “Getting in shape” makes good medical sense.

This is a common question in an orthopedic practice.  The answer lies at the end of an algorithm of treatment options based on science and physician experience.

Orthopaedic problems can be divided into those that are “surgical” and those that are not. The surgical group can be further subdivided into those with absolute (definite) indications and those with relative (reasonable) indications for surgery.

In the absolute group, there is no role for conservative treatment, and surgery is urgent or semi-urgent. These cases typically come through the Emergency Room (“ER”). Examples include open fractures and dislocations, infected joints, and deep lacerations involving nerves and tendons.

In the relative group, conservative treatment is usually tried first, prior to consideration of a surgical solution. Conservative modalities include activity modification, weight loss, Physical Therapy, bracing, anti-inflammatory medications, steroid injections, and observation.  I include the latter because, given enough time, the body will often “heal” itself.

An adequate trial of conservative treatment varies with the specific diagnosis, but generally runs 3 – 6 months. When conservative treatment fails to bring lasting relief from symptoms, surgery is considered.

For a patient at this juncture, asking the right questions of oneself and of one’s surgeon can be of great assistance in coming to a decision. Questions such as those that follow enable a patient to weigh the risks and benefits of the surgery in an informed and meaningful way.  

Sample questions to ask oneself are:

Can I work and function reasonably well with my symptoms?

•  Do I need to be on chronic pain medication to get through the day?
•  Does the pain interrupt my sleep?
•   If I develop a post-operative complication, will I still feel  I made the correct decision to underg0 surgery?

Sample questions to ask one’s surgeon are:

•  What has been your experience with this procedure, and are you comfortable performing it?
•  What is your complication rate following this procedure?
•  When will I reach an end result, and what outcome can I reasonably expect?
•  What will happen if I choose not to undergo the surgery?

By embracing a trial of conservative therapy and asking appropriate questions (particularly if surgery is an option) the patient becomes an active participant in his or her orthopedic treatment.

 “Do I need surgery, Doc?”  Since most orthopaedic problems are not surgical, the answer is usually ‘Probably not”.  If a  patient does end up in the surgical group , however,  full participation in his or her own healthcare decision makes for a result better understood and therefore more satisfactory for both patient and physician.